Mediation Request Form

Domestic Relations Office
Request a Mediation
Cause Number*
Referring Court*
Ordered by Court*
What party is this submitted for?*
Is the client's primary language English?*

YesNo
If no, what language:*
The Domestic Relations Office does not provide translation services and the party or their attorney will need to provide a translator.
Name*
Relationship to Children*
Primary Phone Number*
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.
Email Address*

Confirmation Email
Date of Birth*

MonthDayYear
Occupation*
Gross Annual Income*
Does Party have an Attorney*
Attorney Information
Name*
Email Address*

Confirmation Email
Phone*
Please enter a valid phone number.
Cell Phone*
Please enter a valid phone number.
Other Party
Other Party Name*
Other Party Phone
Is there an Amicus Attorney involved
Amicus Attorney
Name
Email Address

Confirmation Email
Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Children
Child One Name*
Child One Date of Birth*

MonthDayYear
Child Two Name
Child Two Date of Birth

MonthDayYear
Child Three Name
Child Three Date of Birth

MonthDayYear
Child Four Name
Child Four Date of Birth

MonthDayYear
Child Five Name
Child Five Date of Birth

MonthDayYear
Case Details
Is the Office of Attorney General Involved in this Case?*
Attorney General Information
Name
Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Unit Number(s)
Is the OAG a Petitioner or Intervenor in this case?
Please provide the OAG # for this case.
Type of Case?*
Date of Marriage/Relationship

MonthDayYear
Date of Separation

MonthDayYear
Is there a Temporary Order?*
Date of Temporary Order?

MonthDayYear
Children are residing with?*
Active CPS Case?*
Active protective order?*
If active protective order, against whom?
Issues to be mediated:*

CustodyChild SupportPossession/AccessPropertyOther
Briefly state what the party desires to achieve in mediation:*

0/80
Has a party been struck, kicked, bitten, choked, burned or otherwise hurt by the other party?*
If yes, please explain:

0/80
Has a party been threatened or hurt with a knife, gun or other object by the other party?*
If yes, please explain:

0/80
Has a party been emotionally abused or verbally threatened by the other party?*
If yes, please explain:

0/80
Have the children been abused, beaten, neglected or otherwise deliberately injured?*
If yes, please explain:

0/80
Have you any reason to believe that a party uses illegal drugs or abuses alcohol or prescription drugs?*
If yes, please explain:

0/80
Have you any reason to believe that the other party is suicidal or not able to make rational decisions regarding the children due to mental or emotional illness?*
If yes, please explain:

0/80
Please enter the name of person that filled in this form*
Please enter the email of person that filled in this form*
What is the relationship of the person completing the form to the case?*
As the person filling out this form, I understand that by checking this box, I agree that the attorneys and clients will comply with the following statement:*
As the person filling out this form, I understand that by checking this box, I agree that the attorneys and clients will comply with the following statement:*
Should be Empty: